Insomnia, the most common sleep complaint, is the feeling that you have not slept well or long enough. It occurs in many different forms. Most often it is characterized by difficulty falling asleep (taking more than 30 to 45 minutes), awakening frequently during the night, or waking up early and being unable to get back to sleep.

With rare exceptions, insomnia is a symptom of a problem, and not the problem itself. Good sleep is a sign of health. Poor sleep is often a sign of some malfunctioning and may signal either minor or serious medical or psychiatric disorders. Insomnia can begin at any age. And, it can last for a few days (transient insomnia), a few weeks (short-term insomnia), or indefinitely (long-term insomnia).

Transient insomnia may be triggered by stress-- a hospitalization for surgery, a final exam, a cold, headache, toothache, bruised muscles, backache, indigestion, or itchy rash. It can also be caused by jet travel that involves rapid time-zone change.

Short-term insomnia, lasting up to 3 weeks, may result from anxiety, nervousness, and physical and mental tension. Typical are worries about money, the death of a loved one, marital problems, divorce, looking for or losing a job, weight loss, excessive concern about health, or plain boredom, social isolation, or physical confinement.

Long-lasting distress over lack of sleep is sometimes caused by the environment, such as living near an airport or on a noisy street. Working a night shift can also cause problems: sleeping during the day may be difficult on weekdays, especially when the person sleeps at night on weekends. But more often, long-term insomnia stems from such medical conditions as heart disease, arthritis, diabetes, asthma, chronic sinusitis, epilepsy, or ulcers. Long-term impaired sleep can also be brought on by chronic drug or alcohol use, as well as by excessive use of beverages containing caffeine and abuse of sleeping pills.

Many patients with long-term insomnia may be suffering from an underlying psychiatric condition, such as depression or schizophrenia. Depression, in particular, is often accompanied by sleep problems (which usually disappear when the depression is treated). People with phobias, anxiety, obsessions, or compulsions are often awakened by their fears and worries, sometimes by nightmares and feelings of sadness, conflict, and guilt.

Insomnia is a complex problem, not given to simple solutions. Most experts agree that treatment should start with assessing and correcting sleep hygiene and habits.

Exercise
Regular exercise tends to benefit sleep, but not right at bedtime. Vigorous exercise, especially just before sleep, can cause arousal and delay sleep. You cannot force sleep on a given night by exercising excessively during the day. Exercise in the morning also has little beneficial effect on sleep. The best time to exercise is in the afternoon or early evening. But, even then, it probably won't help you sleep unless you exercise on a regular schedule.

Trying Too Hard
Trouble falling asleep, the most common form of sleep disturbance, may be brought on simply by going to bed too early. Sleep cannot be forced. You should not go to sleep until you are sleepy. If you turn in too early--even if you do fall asleep--you could experience a disturbed night's rest or could wake early without feeling refreshed. If you go to bed when you feel sleepy but find that you can't fall asleep, don't stay in bed brooding about being awake. It is best to get out of bed. Leave the bedroom. Read, sew, watch TV, take a warm bath, or find some other way to relax before slipping between the sheets once more.

Naps
Laboratory tests have shown that daytime naps disrupt normal nighttime sleep. Although many people feel like napping between 2 and 4 p.m. (siesta time), most sleep better if they don't nap during the day. Naps should not be used as a substitute for poor sleep at night. However, there are exceptions to this general rule. Many older people, in particular, do sleep better at night when they take daytime naps. But if you are a napper who sleeps poorly at night, your nighttime sleep might improve if you skip the naps.

Bedtime Snacks
If hunger keeps you awake, a light snack might help you sleep, unless it causes problems with digestion. Avoid heavy meals, alcohol, and caffeine-containing coffee, tea, and cola. For those who can tolerate milk, that old, time-tested remedy may work best.

Smoking At Bedtime
Nicotine stimulates the nervous system and can interfere with sleep. In one sleep laboratory study, smokers experienced greater difficulty than nonsmokers. Sleep patterns also improved significantly among chronic smokers when they abstained from smoking.

Alcohol
The effect of alcohol is deceiving. It may induce sleep, but chances are it will be a fragmented sleep. The sleeper will probably wake up in the middle of the night when the alcohol's relaxing effect wears off.

Regular Bedtime
The best way to sleep better is to keep a regular schedule for sleeping. Go to bed at about the same time every night, but only when you are tired. Set your alarm clock to awaken you about the same time every morning--including weekends and regardless of the amount of sleep you have had. If you have a poor night's sleep, don't linger in bed or oversleep the next day. If you awaken before it is time to rise, get out of bed and start your day. Most insomniacs stay in bed too long and get up too late in the morning. By establishing a regular wakeup time, you help solidify the biological rhythms that establish your periods of peak efficiency during the 24-hour day.

Sleeping Pills: A Temporary Solution
All brands of prescribed sleeping pills are hypnotics--that is, drugs that depress the central nervous system and put users to sleep. A variety of hypnotics are now on the market, including barbiturates, benzodiazepines, and several classes of drugs generally referred to as the nonbarbiturates/nonbenzodiazepines.

The benzodiazepines are very toxic when taken in combination with alcohol. Benzodiazepine drugs sometimes can aid sleep for up to 30 days. The benzodiazepines are not all alike, though. Some work faster than others, some produce effects that last longer, and some are eliminated from the body sooner.

When taken for a brief period and under a doctor's guidance, prescription sleeping pills may help you sleep better. But insomnia cannot be corrected with pills. At best, sleeping pills have only limited usefulness. They provide a temporary solution to insomnia. Thus, only when a person's health, safety, and well-being are threatened should sleep-promoting drugs be considered and then only after the doctor takes a medical history and does a physical examination. He or she might identify conditions that should not be treated with sleeping pills and weigh other risks during treatment.

Although temporarily helpful, sleep promoting medications can eventually cause disturbed sleep, side effects, a sleep "hangover" during the day, and dependence on the drug. Furthermore, once the drugs are stopped, sleep problems return, at least temporarily, and may be even more severe than they were before the medication was first taken.

Sleeping pills can be fatal when taken in combination with alcohol or other drugs. Even when not fatal, combining drugs and alcohol can be perilous to driving and the use of other machinery. Long-acting sleeping pills, by themselves, may also impair driving performance the day after they are taken. People who are taking sleeping pills should never drink for a couple of days afterward.

Anxiety, Depression, and Sleep

In a recent national survey, 47 percent of those reporting severe insomnia reported a high level of emotional distress. Psychological factors, such as fears, phobias, and compulsions, can so occupy the mind that sleep is delayed, disturbed, or shortened. Chronically tense people are frequently so restless, hyperactive, and apprehensive that they expect not to sleep when they go to bed.

In depressed people, an overwhelming feeling of sadness, hopelessness, worthlessness, or guilt can be associated with abnormal sleep patterns. Often, the depressed person awakens early and cannot return to sleep. Yet, sometimes, just the opposite is true. Some depressed people find relief in sleeping, denying or escaping from the problems of living by sleeping. The loss of a sense of purpose in life may be associated with an overwhelming urge to sleep, a constant feeling of tiredness, or nighttime sleep marked by an irregular sleep/wake pattern.

Many depressed people complain of insomnia without recognizing they are depressed. If you have lost interest in activities you used to enjoy, or if you have feelings of hopelessness or suicidal thoughts, you may be one of them. You should discuss the problem with your physician, who may recommend psychiatric consultation. While the complaint may be insomnia, the underlying depression, not the insomnia, must be treated. Antidepressant medications and/or psychotherapy can produce remarkable improvement, both in mood and sleep patterns.